Provider Demographics
NPI:1427647528
Name:WILLIAMS, KELLY JO (PTA)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:JO
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MRS
Other - First Name:KELLY
Other - Middle Name:JO
Other - Last Name:MARKWARDT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:3422 S 76TH WEST AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74107-4538
Mailing Address - Country:US
Mailing Address - Phone:918-850-7295
Mailing Address - Fax:
Practice Address - Street 1:6715 E 41ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74145-4520
Practice Address - Country:US
Practice Address - Phone:918-806-0106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-13
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2614225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant